Culture Shock: The Slow Progression of the Medical Error Prevention Field

The November 1999 Institute of Medicine (IOM) report, “To Err is Human: Building a Safer Health System,” changed the way health care professionals and the public viewed medical error prevention and brought the medical error field to the forefront. Nearly a decade later, the IOM report is still recognized as the most influential report in the IOM’s history. Despite the report’s credibility and acclaim, an unwillingness to adapt by some in the industry has slowed the progression of a medical field already playing catch-up.

The 1999 IOM report

“To me, that report started the field of patient safety,” Robert M. Wachter, MD, professor and chief of the Division of Hospital Medicine at the University of California, San Francisco, said.

In the report, the IOM provided the now famous estimate that medical errors caused anywhere from “44,000 to 98,000 deaths a year.” The report took the statistic one step further and compared their estimate to other estimated death tolls from 1999. Using the low-end estimate of 44,000 deaths a year, medical errors were still responsible for more deaths than motor vehicles, breast cancer and AIDS.

“When the report came out … [using] terms like ‘this would be the equivalent of a large plane crashing every day,’ resonated with some people,” Wachter said.

This comparison, along with the estimate that preventable medical errors cost the country $17 billion a year, received enough attention from the press and health care professionals to put the spotlight on an industry that was all but unaware of medical error prevention.

“We thought of errors as being human failings and we approached it as an individual problem.” Wachter told O&P Business News. “We have now come to understand that this was largely the wrong approach.”

The results

Robert M. Wachter, MD
Robert M. Wachter, MD
Image reprinted with permission of Robert M. Wachter

The IOM stressed that the majority of medical errors are due to a systems problem, not the individual practitioner. An improved system needed to be implemented. Standardized applications of patient safety systems replaced under-regulated and individualistic systems that did not have medical error prevention as a top priority. Proactive measures including reading back a person’s name and marking the site of a surgery became requirements.

Other improvements suggested in the report included having a pharmacist on medical rounds to help reduce medication errors, hand-held wireless computer technology to eliminate reliance on handwriting and avoidance of similar sounding and look-alike names on packages of medications. According to the Journal of the American Medical Association, computerized physician order entry (CPOE) systems have reduced medication and prescribing errors by as much as 81%.

Requiring a limit to the number of hours a doctor, nurse or health care professional work in a shift would reduce the number of worn down and mentally tired health care professionals at a given time. A tired doctor working at a frantic pace, in a hectic hospital, relying on his or her memory, will undoubtedly lead to preventable errors and will cost the hospital thousands of dollars and put the patient at great risk.

Jon Shreter, CPO, president and general manager of Allied Orthotics and Prosthetics, sites the fit and alignment of prostheses as a cause for concern when discussing medical errors. He also believes one of the challenges facing the industry is the balance between safety and function.

Shreter points out that new technologies have made it easier for prosthetists to create devices that are both safe and functional and the problems that do face the industry have straight-forward solutions.

“The problems are easy to rectify if they are caught because all you have to do is take off the device,” Shreter said. “The thing about O&P is that [the device] is not something that is implanted inside a patient. If it is rubbing you and you feel it, take it off and put it on later or go to a clinician and have it adjusted.”

No satisfaction

Health care professionals are far from pleased with the results over the past nine years. In fact, many health care practitioners are unsatisfied with the slow progress that has been made since the IOM report.

“We have made modest progress as a country regarding the reduction in medical error,” David B. Nash MD, MBA, chair of the Department of Health Policy at Jefferson Medical College, Thomas Jefferson University said. “There is research evidence to support this sad conclusion.”

A study conducted by Samantha Collier, MD, chief medical officer at HealthGrades, a private health study group, illustrates Nash’s description of modest progress.

The April 2007 report indicated hospitals have improved in some areas of error prevention, such as low-risk medical procedures, while worsening in areas such as bed sores and post- surgical blood infections. She reaches a conclusion in her report stating that overall, “not that much has changed.”

Despite its acceptance as a major medical crisis by the health care community, frustration continues to mount over the results.

“We should be making much more progress. It has been incredibly slow,” Nash said.

Changing the culture

David B. Nash, MD, MBA
David B. Nash, MD, MBA
Image reprinted with permission of David B. Nash

What has halted the progression? Nash explained that a complete change in the culture of the medical practitioner and health care system is necessary in order to put a major dent in the medical error crisis.

“It’s basically a huge cultural issue,” Nash said.

According to both Wachter and Nash, a cultural shock to the system has not been accepted by all. Veteran doctors, set in their ways, are more inclined to resist the change. This resistance to change can ultimately cause a major preventable error.

“There are some older physicians that weren’t trained this way and don’t believe in it.” Wachter said. “I believe that if you have physicians that refuse to follow reasonable safety rules that they should not be allowed to practice.”

Why should a well-established practitioner who has never had an incident of negligence, change the way he or she works?

“One of the challenges of patient safety is that you may not think that there is a problem until the day that you cut off the wrong leg,” Wachter said.

Nash believes everyone needs to humble themselves. People involved in the health care system need to take a look in the mirror before they start to hinder their own progress.

“What we have to get out of is the “I’m an expert. I know everything mentality” and get into the mindset of “I’m an expert, but I could always do a better job,” Nash explained to O&P Business News.

Practitioners will make mistakes. Reporting a medical error is part of the humility. It is difficult to strike a balance between a no-blame culture encouraging doctors to report an error they have committed and holding persistent rule violators accountable. According to the National Academy of State Health Policy, 26 states and the District of Columbia have systems in place to report medical errors.

“We know when there is a terrible error that happens on our watch, we have to report it to the state. There’s a decent chance that the state will visit us, see how we responded to it and determine whether we fixed the problems,” Wachter explained.

To Nash, this is an important part of the culture change.

“One of the cornerstones of professionalism means that you are willing to evaluate what you do every day, to try and do a better job,” Nash said. “That’s the challenge.”

More Education

Along with the IOM report, studies continue to indicate that billions of dollars have been wasted and thousands of lives have been lost due to preventable medical errors. Nash’s assessment of the medical error prevention field not only stems from the measured progress but also the surprising lack of education on the subject.

“We still don’t teach a lot of this in medical schools or nursing schools. It’s still not a core part of the curriculum,” Nash explained. “Doctors, nurses and others still don’t appreciate generally, that this is a systems problem. They still define it as an individual practitioner problem.”

Solving the crisis through education has been difficult.

“The typical medical school would say to you, ‘what would you like us to take out so we can put this in?’ But that’s a silly way of thinking of the problem,” Nash said.

Sacrificing one part of the curriculum to improve another is not going to make the current situation better or produce a better practitioner. In trying to reverse this trend, Thomas Jefferson University in Philadelphia has recently opened a new school of Health Policy and Population Health where Nash will be dean. It is the only such school in the country.

Patient role

A study supported by the Agency for Healthcare Research and Quality found that practitioners often do not do enough to help their patients make informed decisions.

In the O&P field, prosthetists rely on the patient. According to Shreter, a patient with cognitive impairment or skin sensation impairment may wear a prosthesis or orthosis and not feel pain. The prosthetist relies on the patient to take an active role in inspecting their device and checking for calluses or sores.

“We have to make sure that we educate the patients properly before they use the device,” Shreter said. “A big part of that education is telling us whether they have problems with the fitting or the function of the prosthesis.”

According to Nash, communication is particularly important. If the doctor can not effectively communicate with you regarding your own health care, do your research and find a new doctor.

“The number one thing is to be informed. Number two, ask a lot of questions. Number three, bring a buddy. Number four, if any of the above annoys the doctor, get a new doctor,” Nash said.

Wachter also believes the patient should be informed, but ultimately the burden is on the hospital and the provider. In Wachter’s view, there is no way a patient can understand all that is involved in diagnosing and treating a patient.

“Particularly in a hospital, the number of patients that are confused, anxious, or don’t speak English is high,” Wachter explained. “Even a health care professional who is a patient will tell you there is only so much that you can do. You’re simply not in a position to prevent most errors.”

Still in the news

A cultural change is often the result of a dramatic event. With no true event to point to, a change in culture has been more difficult to cultivate. However, the IOM report was the spark that changed the way the health care system implemented medical error prevention systems.

“What was interesting was that it was a dramatic report, but it was still just a report,” Wachter said. “It is not that often that it is a report that leads to this kind of drama. Usually it’s a terrible error that makes the news.”

Another IOM-like report is unlikely to emerge due to the fact that the public no longer needs to be shocked into change.

“In the short term, this thing has enough legs that I don’t think its dependent on a continual drumbeat of horrible things,” Wachter explained. “And even if it was, we have them. Every couple of months you pick up a newspaper and you see someone operated on the wrong leg, somebody died of a medication overdose, or the wrong breast was removed. There’s enough of that stuff out there that still keeps the [interest] going.”

Wachter gave the health care system an overall grade of a C+ in his 2004 paper, “The End of the Beginning: Patient Safety Five Years After ‘To Err Is Human.’” Four years later, Wachter gives the health care system a B-, all but agreeing with Nash that the progress has been slow.

The opportunity to improve is in our own hands, according to Nash.

“We have the science. We have the tools. We know what has to be done,” he said. “So it’s basically the political will to change the culture.” — by Anthony Calabro

For more information:

  • Kohn L, Korrigan J, Donaldson M, ed. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National Academy Press; 2000.
  • Wachter RM. The End of the Beginning: Patient Safety Five Years After To Err Is Human. Health Affairs Web Exclusive, Nov. 30, 2004; 534-545.
  • The Journal of the American Medical Association Web site. 2005 role of computerized physician order entry systems in facilitating medication errors. Available at Accessed Oct. 20, 2008.
  • Wachter RM. Understanding Patient Safety, New York: McGraw-Hill, 2008.

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